VAF 21P-8938 Student Beneficiary Report-REPS (Restored Entitlement Pr

OMB Control No. 2900-0399
Respondent Burden: 20 Minutes
Expiration Date: XX/XX/XXXX

STUDENT BENEFICIARY REPORT - REPS
(RESTORED ENTITLEMENT PROGRAM FOR SURVIVORS)
SECTION I - STUDENT IDENTIFICATION

1B. VETERAN/WAGE EARNER'S
SOCIAL SECURITY NO.

1C. STUDENT'S SOCIAL SECURITY NO.

2. PERIOD OF ATTENDANCE

A. BEGINNING DATE (Month, day, year)

B. ENDING DATE (Month, day, year)

1A.NAME AND ADDRESS OF STUDENT(First-middle-last name)

(If different from above, furnish current address.)

INSTRUCTIONS

NOTE: DO NOT USE "NA" OR "UNKNOWN" IN ITEMS REQUIRING COMPLETION.
STUDENTS: You must complete Section II, Student Certification, and have a school official verify your attendance.
SCHOOL OFFICIALS: Please complete Section III, School Official Certification, and return it promptly as failure to do so will result in
suspension of the student's benefit payment. This form should be returned to the VA REGIONAL OFFICE (331/21Q), 400 SOUTH
18TH STREET, ST. LOUIS, MO 63103-2271.
IMPORTANT: THIS FORM SHOULD NOT BE RETURNED TO THE STUDENT.

SECTION II - STUDENT CERTIFICATION

3. NAME OF SCHOOL YOU ATTENDED
DURING PERIOD(S) SHOWN IN ITEM 2

4A. HAVE YOU ATTENDED SCHOOL ON A FULL-TIME BASIS FOR
PERIOD SHOWN IN ITEM 2?

5. LIST DATES OF FULL-TIME
ATTENDANCE IF DIFFERENT
FROM ITEM 2 (Month, day, year)

YES
NO (If "No," complete Item 5)
4B. TYPE OF DEGREE
GRAD
6. WILL YOU CONTINUE SCHOOL ON A FULL-TIME BASIS
AFTER THE END OF THE PERIOD SHOWN IN ITEM 2?

OTHER
7. DATES OF YOUR NEXT SCHOOL YEAR

B. ENDING DATE (Month, day, year)

A. BEGINNING DATE (Month, day, year)

NO (If "Yes," complete Item 7)

YES

8B. NAME AND ADDRESS OF NEW
SCHOOL

8A. WILL YOU ATTEND THE SCHOOL SHOWN IN ITEM 3?

NO (If "No," complete Items 8B thru 8D)

YES

8D. TYPE OF DEGREE
GRAD
UNDERGRAD

YEAR

8C. TYPE OF NEW SCHOOL
COLLEGE OR UNIVERSITY
TECHNICAL, TRADE OR VOCATIONAL

OTHER (Specify)

OTHER

9. EARNINGS/WAGES RECEIVED FOR PRIOR
YEAR (ENTER DOLLAR AMOUNT OR "NONE")

10A. EARNINGS EXPECTED THIS YEAR
(ENTER DOLLAR AMOUNT OR "NONE")

AMOUNT

YEAR

$

10B. EARNINGS EXPECTED NEXT YEAR
(ENTER DOLLAR AMOUNT OR "NONE")

AMOUNT

YEAR

$

11. HAVE YOU OR WILL YOU BE PAID BY YOUR
EMPLOYER FOR ATTENDING SCHOOL?

YES

UNDERGRAD

12A. HAVE YOU EVER BEEN MARRIED?

NO

YES

AMOUNT

$
12B. DATE(S) OF MARRIAGE (Month, day, year)

NO (If "Yes," complete Item 12B)

IMPORTANT: IT IS YOUR DUTY TO REPORT ANY CHANGE IN STATUS. You must notify the VA immediately of any change
in school enrollment, marital or work status, as benefits may be affected.
I CERTIFY THAT the previous statements are true and correct to the best of my knowledge and belief.
13B. CLAIMANT'S TELEPHONE NUMBER (Include Area Code)

13A. SIGNATURE OF CLAIMANT

13C. DATE SIGNED (Month, day, year)

SECTION III - SCHOOL OFFICIAL CERTIFICATION

14. HAS THE STUDENT MAINTAINED FULL-TIME
STATUS BY THE SCHOOL'S STANDARDS
DURING THE ENTIRE PERIOD SHOWN IN ITEM 2?
(AT LEAST 20 CLOCK HOURS IS CONSIDERED
FULL-TIME FOR NON-COLLEGE DEGREE)

YES

15A. LIST DATES OF FULL-TIME ATTENDANCE, INCLUDING LAST DATE OF FULL-TIME
ATTENDANCE WHEN A COURSE WITHDRAWAL IS INVOLVED

15B. IF TERM CLAIMED IN ITEM 7 HAS BEGUN, IS STUDENT STILL FULL-TIME?
YES
NO

NO (If "No," complete Item 15)

16A. NAME OF SCHOOL

16C. TYPE OF SCHOOL

16B. TELEPHONE NUMBER OF SCHOOL OFFICIAL
(Include Area Code)

16D. TYPE OF DEGREE
GRAD
UNDERGRAD

COLLEGE OR
UNIVERSITY

TECHNICAL, TRADE
OR VOCATIONAL

OTHER

17. ENTER CLOCK HOURS ATTENDED
PER WEEK IF NOT A DEGREE
GRANTING PROGRAM

OTHER

18A. SIGNATURE AND TITLE OF SCHOOL OFFICIAL

18B. DATE SIGNED (Month, day, year)

PENALTY: The law provides severe penalties which include fine or imprisonment or both for the willful submission of any statement or evidence of
a material fact, knowing it to be false or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
XXX XXXX

21P-8938

SUPERSEDES VA FORM 21-8938, MAY 2014,
WHICH WILL NOT BE USED.

PRIVACY ACT NOTICE
The VA will not disclose information collected on this form to any source other than what has been authorized
under the Privacy Act of 1974 or Title 5, Code of Federal Regulations 1.526 for routine uses (i.e., (Routine
Uses 1 through 63) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension,
Education, and Vocational Rehabilitation and Employment Records - VA, and published in the Federal
Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account
information is voluntary. No benefits may be granted unless this form is completed fully as required by law (38
U.S.C. 5101). Refusal to provide your SSN by itself will not result in the denial of benefits. The VA will not deny
an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a
Federal Statute of law in effect prior to January 1, 1975, and still in effect.

IMPORTANT NOTICE ABOUT INFORMATION COLLECTION
We need this information in order to determine your continued eligibility for REPS payments as a student
beneficiary. Title 38, United States Code, allows us to ask for this information. We estimate that you will need
an average of 20 minutes to review the instructions, find the information, and complete this form. VA cannot
conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control numbers
can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21P-8938, XXX XXXX